HEALTH SAVINGS CUSTODIAL ACCOUNT AGREEMENT
(Under section 223(a) of the Internal Revenue Code)
butions to this HSA exceed the maximum annual contribution limit, including the catch-up
contribution limit, if applicable, the Account Owner shall notify the Custodian that there
The Account Owner named on the HSA Application is establishing this Health Savings
exist excess contributions to the HSA. It is the responsibility of the Account Owner to
Account (HSA) exclusively for the purpose of paying or reimbursing Qualified Medical
request the withdrawal of the excess contribution and any net income attributable to such
Expenses of the Account Owner, his or her spouse, and tax dependents. The Account
excess contribution. It is also the Account Owner’s responsibility to ensure that any emOwner represents that unless this account is used solely to make rollover contributions, he ployer contributions due are made to the HSA. Custodian shall not be liable for any losses,
or she is eligible to contribute to this HSA; specifically, that he or she: (1) is (or will be as
damages, costs, penalties, or expenses the Account Owner incurs as a result of any emof the effective date of this Agreement) covered under a High Deductible Health Plan
ployer’s failure to make any contributions to his or her HSA. Custodian is not responsible
(HDHP); (2) is not also covered by any other health plan that is not an HDHP (with certain for monitoring any employer’s HSA contributions or notifying any Account Owner of emexceptions for plans providing preventive care and limited types of permitted insurance
ployer contributions or the failure of any employer to make a contribution. In considering
and permitted coverage); (3) is not enrolled in Medicare; and (4) cannot be claimed as a
whether contributions have exceeded the allowable annual contribution limit, Account
dependent on another person's tax return.
Owner must take into account any employer contributions as well as any transfers or
contributions previously made to this HSA or to any other HSA that also count toward the
Agreement
annual contribution limit.
The Account Owner hereby designates FPS Trust Company, LLC as the Custodian under
ARTICLE IV — Vested Status
this Custodial Account Agreement and has deposited or transferred to this Custodial Account an initial HSA contribution. The Account Owner and the Custodian make the followThe Account Owner's interest in the balance in this Custodial Account is nonforfeitable.
ing Agreement:
ARTICLE V — Prohibited Use of Funds
ARTICLE I — Contributions
1.
No part of the Funds in this Custodial Account may be invested in life insurance
1.
The Custodian will accept additional cash contributions for the tax year made by the
contracts or in collectibles as defined in Section 408(m) of the Internal Revenue
Account Owner or on behalf of the Account Owner (by an employer, family member
Code.
or any other person). No contributions will be accepted by the Custodian for any
Account Owner that exceed the IRS maximum amount for family coverage plus the
2.
The assets of this Custodial Account may not be commingled with other property
catch-up contribution for the calendar (tax) year for which the contribution is made.
except in a common trust fund or common investment fund.
Account Owner Representations
2.
Contributions for any tax year may be made at any time before the deadline for filing
the Account Owner's federal income tax return for that year (without extensions).
3.
Rollover contributions from an HSA or an Archer Medical Savings Account (Archer
MSA) (unless prohibited under this Agreement) are not subject to the maximum
annual contribution limit set forth in Article II. The Custodian reserves the right to
refuse any transfer or rollover and is under no obligation to accept investments other
than cash. The Custodian will not accept a transfer of property it cannot legally hold
or any amount that the Custodian determines is an ineligible investment in the Custodial Account.
4.
3.
ARTICLE VI — Distributions
1.
Distributions of Funds from this HSA may be made upon the direction of the Account
Owner. The Account Owner may request a distribution through the Administrator’s
website or by completing the HSA reimbursement form. Distribution requests other
than using a completed and signed form or initiating a reimbursement through the
website will not be honored (e.g., by phone or email). If a debit card is made available in connection with the HSA, the additional provisions in Article XI, Section 10
apply.
2.
Distributions from this HSA that are used exclusively to pay or reimburse Qualified
Medical Expenses of the Account Owner, his or her spouse, or tax dependents are
tax-free. However, distributions that are not used for Qualified Medical Expenses are
included in the Account Owner's gross income and are subject to an additional 20
percent tax on that amount. The additional 20 percent tax does not apply if the distribution is made after the Account Owner's death, disability, or reaching age 65.
3.
The Custodian is not required to determine whether the distribution is for the payment or reimbursement of Qualified Medical Expenses. Only the Account Owner is
responsible for substantiating that the distribution is for Qualified Medical Expenses
and must maintain records sufficient to show, if required, that the distribution is taxfree. Please consult a tax advisor regarding the tax treatment of any distributions
from the Account.
Qualified HSA funding distributions from an individual retirement account must be
completed in a trustee-to-trustee transfer and are subject to the maximum annual
contribution limit set forth in Article II.
ARTICLE II — Contribution Limits
1.
The maximum annual contribution limit for an Account Owner with single coverage
and the maximum annual contribution limit for an Account Owner with family coverage are established each year by the Internal Revenue Service (IRS). These limits
are subject to cost-of-living adjustments each calendar year. Contribution limits for
the current year may be found at www.treasury.gov or in IRS Publication 969.
2.
Contributions to Archer MSAs or other HSAs count toward the maximum annual
contribution limit to this HSA.
3.
An additional $1,000 catch-up contribution may be made for an Account Owner who
is at least age 55 or older at any time during the tax year and not enrolled in Medicare.
4.
Contributions in excess of the maximum annual contribution limit are subject to an
excise tax. However, the catch-up contributions are not subject to an excise tax.
5.
The Account Owner will be responsible for any tax consequences that result
from exceeding the contribution limits set annually by the Internal Revenue
Service for single or family coverage.
ARTICLE III — Account Owner Responsibility
It is the responsibility of the Account Owner to determine whether contributions to this
HSA have exceeded the maximum annual contribution limit described in Article II. If contri-
Neither the Account Owner nor the Custodian will engage in any prohibited transaction with respect to this account (such as borrowing or pledging the account or engaging in any other prohibited transaction as defined in Internal Revenue Code
Section 4975).
ARTICLE VII — Successor in Interest
If the Account Owner dies before the entire interest in the account is distributed, the entire
account will be disposed of as follows:
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If the Beneficiary is the Account Owner's spouse, the HSA will become the spouse's
HSA as of the date of death.
If the Beneficiary is not the Account Owner's spouse, the HSA will cease to be an
HSA as of the date of death. If the Beneficiary is the Account Owner's estate, the fair
market value of the account as of the date of death is taxable on the Account Own-
applicable, in order to qualify as a “high” deductible health plan. These limits are
subject to cost-of-living adjustments each calendar year. Limits for the current year
may be found at www.treasury.gov or in IRS Publication 969.
er's final return. For other Beneficiaries, the fair market value of the account is taxable to that person in the tax year that includes such date.
ARTICLE VIII — Tax Reports
1.
The Account Owner agrees to provide the Custodian with any information necessary
for the Custodian to prepare any report or return required by the IRS.
2.
The Custodian agrees to prepare and submit any report or return as prescribed for
custodians of an HSA by the IRS. In addition, the Custodian may execute any declarations or certificates pertaining to the HSA that may be required under any tax law
(s) or governmental regulation(s) now or hereafter in effect without prior approval of
the Account Owner. Custodian shall provide the Account Owner all information regarding the HSA that is under its control as is necessary for the Account Owner to
file all required returns, reports, or other documents to the applicable taxing authorities. It is solely the Account Owner’s responsibility to comply with all applicable reporting requirements with respect to the HSA, including any reports required pursuant to Internal Revenue Code Section 223(h).
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ARTICLE IX — Precedence of IRS Rules
Notwithstanding any other article that may be added or incorporated in this Agreement, the
provisions of Articles I through VIII and this sentence are controlling. Any additional article
in this Agreement that is inconsistent with Section 223 of the Internal Revenue Code or
IRS published guidance with respect to an HSA will be void.
Account Owner's Representations and Responsibilities. The Account Owner
represents that all information that the Account Owner has provided or will provide to
the Custodian under this Agreement is complete and accurate and the Custodian
may rely upon it. The Account Owner will comply with all legal requirements governing this Agreement and the HSA and assumes all responsibility for his or her actions
including, but not limited to, eligibility determination, contributions, distributions,
penalty infractions, proper filing of tax returns and compliance with the Internal Revenue Code and other applicable law in connection with this Agreement.
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Definitions
Account Owner. Account Owner means the individual named as the HSA owner on
the Application for whose benefit the HSA is established.
Agreement. Agreement means and includes this Health Savings Custodial Account
Agreement, the Account Application, Disclosure Statement, and accompanying
documentation. The Agreement may be amended from time to time as provided in
Article X and this Article XI.
Application. Application means the legal document that establishes this Health
Savings Account (HSA) after acceptance by the Custodian. The information and
statements contained in the Application are incorporated into this HSA Agreement.
Authorized Agent. Authorized Agent means any person or entity, including an investment manager or adviser, named by the Account Owner in accordance with
procedures acceptable to the Custodian and authorized by the terms of this Agreement and such appointment to give Instructions to the Custodian, or to vote or otherwise manage the investment of any asset of the Custodial Account.
Self-Only Coverage and Family Coverage. Under an HDHP. Family medical coverage means coverage that is not self-only coverage.
3.
ARTICLE XI — Additional Provisions
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Regulations. Regulations mean the U.S. Treasury Regulations.
Custodian’s Responsibilities. The Custodian, as agent of the Account Owner, but
not as fiduciary, shall take, hold, invest, and distribute all of the assets of the Fund in
accordance with the terms of this Agreement. The Custodian will serve as a nondiscretionary, directed custodian of the Custodial Account. The Custodian is responsible for maintaining custody of the assets held in the Custodial Account, and for
investing those assets as directed by the Account Owner or his or her Authorized
Agent. Notwithstanding the foregoing, the Custodian has the right to liquidate assets
in the HSA if necessary to make distributions or to pay fees, expenses, or taxes
properly chargeable against the HSA. If the Account Owner fails to direct the Custodian as to which assets to liquidate, the Custodian may decide, in its complete and
sole discretion, which assets shall be sold and the Account Owner agrees not to hold
the Custodian liable for any adverse consequences that may result from such decision. Custodian does not guarantee and is not liable for the performance or privacy
of any online system, web site or the Internet. Web site access may be unavailable at
times such as when (a) systems require regular maintenance or upgrades; (b) unforeseen maintenance is necessary; or (c) major unforeseen events occur, such as
earthquakes, fires, floods, computer failures, interruption in telephone service, electrical outages, civil unrest or riots, war, or acts or threatened acts of terrorism, or other
circumstances beyond Custodian’s control. Custodian is not under any circumstance
liable for the unavailability of access to the web site, data entry errors and other
errors made by Account Owner, or for any direct or indirect or consequential loss for
any reason associated with web site or online access or use.
This Agreement will be amended from time to time to comply with the provisions of the
Internal Revenue Code (“Code”) or IRS published guidance. Any amendment made by the
Custodian to comply with the Code and related regulations does not require the Account
Owner’s consent. Other amendments may be made with the consent of the Custodian and
the Account Owner and in compliance with the Amendment provisions in Article XI. The
Account Owner will be deemed to have consented to any amendments 30 days from the
date the amendment is mailed to the Account Owner.
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Qualified Medical Expenses. Qualified Medical Expenses are amounts paid for
medical care as defined in Section 213(d) of the Internal Revenue Code for the
Account Owner, his or her spouse, or tax dependents, but only to the extent that
such amounts are not compensated for by insurance or otherwise. With certain
exceptions, health insurance premiums are not Qualified Medical Expenses.
2.
ARTICLE X — Amendment
1.
Instruction. An Instruction to the Custodian is any oral, written or electronic direction
given in a form and manner required or accepted by the Custodian. The Custodian
may require that any Instruction be in writing or in an electronic format, and may
recognize standing requests, directions, or requisitions as Instructions.
Subject to the policies and practices of the Custodian, the Account Owner may
delegate certain responsibilities by appointing an Authorized Agent in writing in a
form and manner acceptable to the Custodian. Upon receipt of Instructions from the
Account Owner and proof of acceptance by the Authorized Agent, the Custodian may
fully rely on Instructions from the Authorized Agent as if the Custodian had received
the Instructions from the Account Owner.
Beneficiary. Beneficiary means the person(s) or entity(ies) the Account Owner
designates in writing in a form and manner acceptable to the Custodian that will be
entitled to receive the proceeds in the Custodial Account upon the death of the Account Owner.
The Account Owner will pay the Custodian reasonable compensation for its services,
as disclosed in the applicable fee schedules, as amended from time to time. The
Account Owner is responsible for determining the suitability of the High Deductible
Health Plan associated with this HSA. The Account Owner agrees to indemnify and
hold the Custodian harmless from any adverse consequences or losses incurred
based on the representations, statements, actions or inactions of the insurance company or agent that sold the Account Owner the HDHP associated with this HSA. The
insurance agent or agency is not the Custodian’s partner, agent, affiliate, representative or co-venturer.
Custodian. FPS Trust Company, LLC, a Colorado limited liability company, or any
successor thereto. The Custodian of an HSA must be a bank, an insurance company, a person previously approved by the IRS to be a custodian of an individual retirement account (IRA) or Archer MSA, or any other person approved by the IRS.
Fund. Fund means all of the money, securities, debt instruments and other property
which may be transferred, assigned and delivered to the Custodian from time to time
to be held in custody hereunder in the Custodial Account, together with the investments made with them, the proceeds received from them, and the gains and accumulations on them, and the portion thereof from time to time remaining, to be held
and disposed of by the Custodian (without distinction between principal and interest)
in accordance with the terms and provisions of this Agreement and proper directions
received by the Custodian.
Account Owner shall have a password that will allow Account Owner access to his/
her HSA online. It shall be Account Owner’s sole responsibility to keep the password
private. Account Owner shall be responsible for all actions taken by any person using
Account Owner’s password, whether or not such use was authorized by Account
Owner. In the event that Account Owner has provided an electronic signature to
Custodian in connection with an account application or other click sign agreement,
Account Owner agrees Custodian may rely on such electronic signature for purposes
of Account Owner’s authorization of withdrawals or third-party transfers, notices to
change of name or address, or other instructions to Custodian. Custodian shall not
be required to obtain Account Owner’s physical signature for such purposes or any
other purpose, except as may be required by law.
High Deductible Health Plan (HDHP). An HDHP is a health plan that provides selfonly or Family medical coverage and that has a minimum annual deductible and an
annual out-of-pocket maximum (deductibles, co-payments and other amounts, but
not premiums) that meet IRS limitations for self-only or Family medical coverage, as
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4.
Investment Responsibilities. The Account Owner will control and manage the
investment of the Custodial Account except insofar as the Account Owner delegates
investment authority over part or all of the Custodial Account assets to one or more
investment managers or other Authorized Agents. Account Owner grants to the
Custodian all powers reasonably necessary to carry out its investment and other
duties under this Agreement, and Account Owner agrees to furnish the Custodian
with such information and Instructions as may be necessary to carry out the provisions of this Agreement and to enable the Custodian to fulfill all legal and regulatory
reporting requirements.
Account Owner acknowledges and agrees that a prospectus has been made available to Account Owner electronically prior to and following the purchase of any available mutual funds. To the extent that Account Owner directs investment of his or her
Account in mutual funds, balances invested in those mutual funds are subject to
investment fees and other charges and expenses as described by the applicable
prospectuses. Some mutual funds may charge a redemption fee. Redemption fees, if
any, will be charged to the assets held in the HSA. Account Owner cannot reimburse
his or her HSA for redemption fees. For further information on redemption fees,
please see the mutual fund prospectus.
The Custodian will determine the investment options available within the Custodial
5.
Account. These investments will be permissible investments under the applicable
laws and Regulations. The Custodian may change its investment options from time to
time and the Account Owner may move his or her monies in the Custodial Account to
different investments. Any investment changes within the Custodial Account are
subject to the terms and conditions of the investments, including but not limited to
minimum deposit requirements and early redemption penalties.
Beneficiary Designation. The Account Owner may designate one or more persons
or entities as primary and contingent Beneficiaries by completing a written designation in a form and manner acceptable to the Custodian, filed with the Custodian
during the Account Owner’s lifetime. Unless otherwise indicated, all subsequent
Beneficiary designations revoke all prior designations. Beneficiaries may be changed
or revoked by the Account Owner at any time by executing a written designation in a
form and manner acceptable to the Custodian.
Account Owner acknowledges that a wide array of investment options is made available for the investment of funds held in the HSA. Account Owner understands and
agrees that the Custodian is not providing any investment advice to Account Owner
or any Authorized Agent and that Custodian is not an investment adviser registered
under the Investment Advisers Act of 1940. Account Owner also acknowledges that
some of the mutual funds or other investment options that are offered for purchase in
the HSA may pay marketing and administrative services or other “revenue sharing”
fees, including but not limited to so-called “12b-1” fees, to the Custodian in connection with an investment in such funds.
If the Account Owner is married and subject to the marital or community property
laws that require the consent of the Account Owner's spouse to name a Beneficiary
other than or in addition to such spouse, the Account Owner acknowledges that he or
she is solely responsible for compliance with such legal requirements and agrees to
hold the Custodian harmless with respect to any failure to so comply.
No investment transaction for the Custodial Account that is to be processed by the
Custodian at the direction of the Account Owner or an Authorized Agent will be processed until the Custodian receives the Instruction in proper form. Investment transactions will be processed either as soon as administratively practicable thereafter or,
if later, on the scheduled date for processing. The Custodian may rely conclusively
on all Instructions given by the Account Owner or Authorized Agent which the Custodian believes to be genuine. The Custodian’s records of a transaction will be conclusive as the content of any Instructions. Upon application by the Account Owner, on a
form acceptable to the Custodian and upon approval by the Custodian, the Custodian
will accept non-written Instructions from the Account Owner or Authorized Agent
subject to immediate confirmation of such Instructions by email or in writing by the
6.
Authorized Agent.
The Custodian will have no responsibility to see that any investment directions comply with the law and Regulations applicable to an HSA. However, if the Custodian
receives any direction from the Account Owner or an Authorized Agent that appears
to the Custodian in its sole judgment to be incomplete or unclear, the Custodian will
not be required to act on such directions and may hold uninvested any asset without
liability until proper directions are received from the Account Owner or the Authorized
Agent. If investment directions are incomplete or unclear, the Custodian will notify the
Account Owner or the Authorized Agent within a reasonable period of time. In the
absence of proper investment directions, the Custodian will not be liable for interest
or market gains or losses on any cash balances maintained in the Custodial Account.
Upon the Account Owner's death, if the primary designated Beneficiary is the Account Owner's surviving spouse, the Custodial Account becomes the Custodial Account of such surviving spouse. If the primary designated Beneficiary is someone
other than a surviving spouse, the Custodial Account ceases to be an HSA as of the
date of death and the Custodial Account, less any amounts retained to pay outstanding fees and expenses, will be distributed to such Beneficiary as soon as administratively practicable. If no primary Beneficiaries survive the Account Owner, the Custodial Account will be paid to surviving contingent Beneficiaries, if any. If no primary or
contingent Beneficiaries survive the Account Owner or if the Account Owner fails to
designate Beneficiaries during his or her lifetime, the Account Owner's estate shall be
the Beneficiary. No payment will be made to any Beneficiary until the Custodian
receives appropriate evidence of the Account Owner's death, as determined by the
Custodian in its sole discretion, and all fees and expenses applicable to the Account
have been paid or satisfied from Account assets.
Amendment and Termination. The Custodian may amend this Agreement at any
time to comply with legal and regulatory changes or to modify the Agreement as the
Custodian determines advisable. Any such amendment will be sent to the Account
Owner at the last known address on file with the Custodian. The amendment will be
effective on the date specified in the notice to the Account Owner.
The Account Owner may terminate this Agreement at any time by providing 30 days
advance written notice of such termination to the Custodian in a form and manner
acceptable to the Custodian. As of the date of receipt of the termination notice, the
Custodian will no longer accept additional deposits under the Agreement. Upon
termination of this Agreement, Account Owner agrees to name a successor custodian and notify the Custodian in writing of the name of said successor custodian. In the
event that the Account Owner does not name a successor Custodian, the Custodian
shall distribute the Custodial Account, less any applicable fees or penalties, in cash,
as a single payment to the Account Owner. If this Agreement is terminated, the Custodian may retain a reasonable amount it believes is necessary to cover any fees,
expenses or taxes chargeable against the HSA and any penalties associated with the
early withdrawal of any savings instrument or other investments in the HSA.
Any nondeposit investment product that Account Owner purchases using funds in his
or her HSA, including mutual funds, stocks, and bonds, is not FDIC-insured, is not a
deposit or other obligation of the Custodian,. is not guaranteed by FPS Trust or any
of its affiliates, is not insured by any federal government agency, and is subject to
investment risk, including the possible loss of the principal amount invested.
If the Custodian merges with another organization (or comes under the control of any
federal or state agency) or if the Custodian (or any portion which includes the HSA) is
bought by another organization, that organization (or agency) shall automatically
become the trustee or custodian of the HSA, but only if that organization is the type
of organization authorized to serve as an HSA trustee or custodian. If the Custodian
fails to comply with certain Regulations, or is not keeping the records, making the
returns, or sending the statements that are required by Regulations, the IRS may,
after notifying the Account Owner, require the Account Owner to substitute another
custodian or trustee.
Mutual Fund E-Consent: Account Owner consents to receive electronically the fact
sheets, prospectuses, prospectus supplements, and shareholder reports for any of
the available mutual funds in which Account Owner chooses to invest, and to read
the prospectuses, including any supplements, and to agree to their terms before
investing. Account Owner also consents to review trade confirmations online and in
paper or electronic quarterly statements.
The fact sheets, prospectuses, prospectus supplements, shareholder reports and
account information, including trade confirmations, can be accessed through the HSA
Administrator’s website in hypertext markup language (HTML) and/or Adobe Acrobat
Portable Document Format (PDF). Account Owner may access a document in HTML
with appropriate browser software, such as Microsoft Internet Explorer or equivalent.
To access a document in PDF, Account Owner must have installed Adobe Acrobat
Reader on his or her computer, which may be obtained free of charge at
www.adobe.com. Account Owner acknowledges and agrees that he or she has
communications access to the Internet and is able to access documents in HTML
and PDF without additional hardware and software. Account Owner understands that
these documents can be printed if Account Owner has access to a printer, using the
button on the browser. Account Owner further understands that electronic delivery is
provided free of charge, although other online service provider charges may apply,
and that Account Owner may request paper copies of these documents by calling the
HSA Administrator.
The Custodian may resign at any time by providing 30 days advance written notice to
the Account Owner. Upon receiving such written notice, the Account Owner may
appoint a successor trustee or custodian in writing. Upon such appointment and upon
receiving acknowledgement from the successor trustee or custodian of acceptance of
the Custodial Account, the Custodian shall transfer the Custodial Account, less any
applicable fees or penalties, to the successor trustee or custodian. If no successor
trustee or custodian is appointed and no distribution Instructions are provided by the
Account Owner within 30 days after the termination notice was mailed or transmitted,
the Custodian may, at its own discretion, select a successor trustee or custodian and
transfer the Custodial Account, less any applicable fees or penalties, or may distribute the Custodial Account, less any applicable fees or penalties, in cash, as a single
payment to the Account Owner.
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Custodian takes in good faith hereunder that arises under this Agreement or the
administration of the Fund. The Custodian shall not be liable to Account Owner for
any act, omission, or determination made in connection with this Agreement except
for its gross negligence or willful misconduct. Without limiting the generality of the
foregoing, the Custodian shall not be liable for any losses arising from its compliance
with Instructions from the Account Owner or an Authorized Agent; or executing,
failing to execute, failing to timely execute or for any mistake in the execution of any
Instructions, unless such action or inaction is by reason of the gross negligence or
willful misconduct of the Custodian. The provisions of this Section shall survive the
termination, amendment or expiration of this Agreement.
Custodian also retains the right, after notice to the Account Owner, to transfer the
HSA to another custodian or to liquidate the HSA assets and distribute them to the
Account Owner in a single sum.
7.
8.
Instructions, Changes of Addresses and Notices. The Account Owner is responsible to provide any Instructions, notices or changes of address in writing to the
Custodian or through the website provided. Such communications will be effective
upon actual receipt by the Custodian or any later date specified in writing by the
Account Owner. Any notices required to be sent to the Account Owner by the Custodian will be sent to the last address on file with the Custodian and are effective when
mailed unless a later effective date is specified by the Custodian. If authorized by the
Custodian and provided by the Account Owner in the Application, Account Agreement or other documentation deemed acceptable to the Custodian, an electronic
address is an acceptable address to provide and receive any notices hereunder.
Optional Debit Card. The following provisions apply if a debit card is made available
to Account Owner with respect to the HSA. The use of any debit card in connection
with the HSA may be limited to eligible merchants that provide, among other things,
health care related goods and services that are eligible for reimbursement as Qualified Medical Expenses and that supply applicable MCC codes for verification purposes. When a debit card is used for a purchase through an electronic funds transfer
network, a hold may be placed on the funds available in the HSA that may be necessary to cover the transaction. The hold will be in the amount of the transaction request submitted by the merchant for authorization. Held funds are not available for
withdrawal or distribution during the period the hold is in effect, which will be no more
than 3 business days. The Account Owner is solely responsible for resolving any
disputes with a merchant that accepts the debit card concerning the quality of the
goods and services purchased. Any debit card issued to an Account Owner for use
with the HSA is the property of the Custodian or other issuer of the debit card and
must be returned if requested. The Custodian may also refuse to offer a debit card to
any Account Owner at any time and for any reason, or may terminate the debit card
without notice. If there are not enough funds in the HSA when a debit card transaction is performed, the Custodian may, in its discretion, refuse to pay the transaction
or, if the transaction is paid and the HSA is overdrawn, notify the Account Owner
promptly regarding the amount of money needed to be deposited to cover the overdraft. Account Owner agrees to promptly deposit into the HSA the amount of any
such overdraft, plus pay all applicable fees. If an overdraft is honored by the Custodian, there is no obligation to do so at any future time. It is Account Owner’s responsibility to protect any debit card issued to him or her, to sign the signature panel on the
back of the card upon receipt, and to protect access to the PIN assigned to the debit
card. Custodian is not responsible for any improper use of the debit card.
11.
Limitation of Liability. No claim may be made by the Account Owner against the
Custodian for any lost profits or any special, indirect or consequential damages in
respect of any breach or wrongful conduct in any way related to this Agreement. In
addition, the Custodian is not responsible for monitoring employer contributions or
notifying the Account Owner of any employer contributions to the HSA. The Account
Owner is responsible for contacting his or her employer regarding matters relating to
employer contributions and agrees to indemnify and hold the Custodian harmless for
any costs, penalties, expenses, or losses as a result of the employer's failure to
make contributions to or to properly determine comparable employee contributions
for the Account Owner's HSA. Custodian is also not liable to Account Owner for any
statements, representations, actions, or inactions of any insurance agent or agency
that sells or offers for sale an insurance plan in connection with the HSA. The insurance agent or agency is not our partner, agent, affiliate, representative, or coventurer.
Fees and Charges. The Custodian shall receive compensation for its services under
this Agreement. All fees, which are subject to change from time to time, will be disclosed on the Custodian's fee schedule or other disclosure document provided by the
Custodian. The Custodian will provide the Account Owner 30 days advance written
notice of any fee changes. The Custodian will collect all fees from the cash proceeds
in the Custodial Account. If there is insufficient cash in the Custodial Account, the
Custodian may liquidate investments, at its discretion, to satisfy fee obligations associated with the Agreement. Alternatively, if the Custodian so authorizes and if separate payment of fees or other expenses is permissible under applicable federal and/
or state laws, the fees may be paid separately outside of the Custodial Account. If
the Custodian offers investments other than depository products, the Account Owner
acknowledges that the Custodian or its affiliates may receive compensation from
other parties. In addition, the Custodian or its affiliates will retain any earnings credited on any funds in the Account pending investment direction and pending distribution
as part of its compensation for services provided. The Custodian will also be entitled
to reimbursement for all reasonable and necessary costs, expenses, and disbursements incurred by it in the performance of such services, including, without limitation,
attorneys’ fees. Such compensation and reimbursements shall be a charge against
and may be withdrawn by the Custodian from the Custodial Account within a reasonable time, as specified by the Custodian. Any brokerage commissions attributable to
transactions with the assets in the HSA will be charged to the HSA. The Account
Owner may not reimburse his or her HSA for those commissions.
To the extent not prohibited by law, Account Owner authorizes Custodian to liquidate
and transfer the cash proceeds of any investment Account Owner has selected for
his or her HSA in the event that a negative cash balance exists in the HSA for more
than 10 business days. Custodian will notify Account Owner of the negative cash
balance to give Account Owner the opportunity to make additional contributions, if
allowable, or to sell the investments of Account Owner’s choice to resolve the negative cash balance. If the negative balance is not corrected within a reasonable time
after Custodian notifies Account Owner, Custodian may liquidate any of the HSA
investments, at its discretion, to the extent necessary to bring Account Owner’s balance to a positive amount. In the event that liquidating all of Account Owner’s HSA
investments is not sufficient to resolve the negative balance, Account Owner will be
responsible for any remaining deficiency.
9.
10.
Indemnity. Account Owner hereby agrees to indemnify, defend and hold the Custodian and any parent, subsidiary, related corporation, or affiliates of the Custodian,
including their respective directors, managers, officers, employees and agents, harm12.
less from and against any and all loss, costs, damages, liability, expenses or claims
of any nature whatsoever, including but not limited to legal expenses, court costs,
legal fees, and costs of investigation, arising, directly or indirectly, or resulting from
their reliance upon, or any action taken in good faith in accordance with, any certificate, notice, confirmation, or Instruction, purporting to have been delivered by the
Account Owner or an Authorized Agent. Account Owner waives any and all claims of
any nature it now has or may have against the Custodian and its affiliates, parent
company and their respective directors, managers, officers, employees, agents and
other representatives, which arise, directly or indirectly, from any action that the
Custodian takes in good faith in accordance with any certificate, notice, confirmation,
or Instruction from the Authorized Agent. Account Owner also hereby agrees to
indemnify, defend and hold the Custodian and any parent, subsidiary, related corpo- 13.
ration, or affiliates of the Custodian, including their respective directors, managers,
officers, employees and agents, harmless from and against any and all loss, costs,
damages, liability, expenses or claims of any nature whatsoever, including but not
limited to legal expenses, court costs, legal fees, and costs of investigation, arising,
directly or indirectly, out of any loss or diminution of the Fund resulting from changes
in the market value of the Fund assets; reliance, or action taken in reliance, on Instructions from Account Owner or an Authorized Agent; any exercise or failure to
exercise investment direction authority by Account Owner or by an Authorized Agent;
the Custodian’s refusal on advice of counsel to act in accordance with any investment direction by Account Owner or an Authorized Agent; any other act or failure to
act by Account Owner or an Authorized Agent; any prohibited transaction or disqualification of the HSA due to any actions taken or not taken by the Custodian in reliance
on Instructions from the Account Owner or the Authorized Agent; or any other act the
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Maintenance of Records. The Custodian will maintain adequate records and perform its reporting obligations required under the Agreement. The Custodian's sole
duty to the Account Owner regarding reporting is to furnish the IRS mandated reports
as required in Article VIII of this Agreement. The Custodian may, at its discretion,
furnish additional reports or information to the Account Owner. The Account Owner
will be deemed to have been approved any reports or accounting of the HSA unless
he or she objects to the contents of such report or accounting within thirty (30) days
of its mailing or electronic transmission by the Custodian. Any objections must set
forth the specific grounds on which they are based. Upon approval or deemed approval of any report or accounting, the Custodian shall be forever released from any
and all liability with respect to matters reported.
Miscellaneous.
Minimum Values. The Custodian reserves the right to establish HSA, deposit and/or
withdrawal minimums and/or limitations on the frequency of withdrawals. The Custodian may resign or charge additional fees if the minimums are not met.
Other Providers. At its discretion, the Custodian may, without the consent of the
Account Owner, appoint other service providers to fulfill certain of its obligations
hereunder, including reporting responsibilities, and may compensate such service
providers accordingly.
Applicable Law. This Agreement shall be construed and interpreted according to the
laws of the State of Colorado to the extent that such laws are not preempted by the
laws of the United States of America. All contributions to, and payments from, the
Account shall be deemed to take place in the State of Colorado. All controversies,
disputes, and claims arising under this Agreement and not otherwise resolved will be
and record information that identifies each person or entity that opens an account,
including any deposit account, treasury management account, loan, other extension
of credit, or other financial services product. What this means for Account Owner:
When Account Owner opens an account, the Custodian will ask for Account Owner’s
name, taxpayer identification number, residential address, date of birth, and other
information that will allow the Custodian to identify Account Owner. The Custodian
may also ask to see Account Owner’s driver’s license or other identifying documents.
submitted to the United States District Court for the district where the Custodian has
its principal place of business, and by executing this Agreement, each party hereto
consents to that court’s exercise of personal jurisdiction over them.
14.
USA Patriot Act Notification. The following notification is provided to Account Owner pursuant to Section 326 of the USA Patriot Act of 2001, 31 U.S.C. Section 5318:
IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW
ACCOUNT. To help the government fight the funding of terrorism and moneylaundering activities, Federal law requires all financial institutions to obtain, verify,
AGREEMENT AND DISCLOSURE
Participant represents and warrants that he/she has received, read and is in agreement
with all terms in the FPS Terms and Conditions , the HSA Custodial Account Agreement ,
FPS’s privacy policy, the summary of fees and any applicable addendums to the Participant Agreement. Participant agrees to be bound by the terms of the Participant Agreement
(including the terms of incorporated documents), which may be changed, from time to
time, upon notice from FPS Trust.
Participant appoints FPS Trust Company, LLC (“FPS”) as custodian for the HSA established by the HSA Enrollment and Agreement Form and authorizes FPS (including its
affiliates) to perform relevant custodial and administrative services. Participant acknowledges Health Savings Administrators (including its affiliates) as recordkeeper of the HSA
established by the HSA Enrollment and Agreement Form and authorizes Health Savings
Administrators to perform relevant recordkeeping and administrative services.
Participant understands and agrees that FPS may provide online access to the account
through the issuance of usernames and passwords to Participant and other persons.
Participant authorizes access to the account to the Authorized Signers, if any, listed. Further, FPS may provide usernames and passwords to Plan Administrators and/or other
authorized persons/entities. Participant understands and agrees that persons/entities to
which usernames and passwords are issued are solely responsible for the security of the
username and password issued to him/her/it. FPS shall be entitled to rely on the entry of a
username and password into FPS’s systems as confirmation of the identity of the person/
entity to whom the username and password were issued.
Asset based fees will be assessed on a quarterly billing cycle and will be assessed, pro
rata, from the assets in the account. The administration fee will be assessed to the account annually. Participant understands and agrees that these fees may change, from
time to time, upon notice from FPS.
Participant understands and agrees that certain transaction fees may apply to the account.
Participant understands and agrees that these fees may change, from time to time, upon
notice from FPS.
Participant authorizes and instructs FPS to assess referenced fees (and any other fees
Participant may later agree to have assessed against the account) against the account
registered in the Participant’s name established under this HSA Enrollment and Agreement Form.
SUMMARY OF FEES
Administrative Fee: $45 per year. Fee deducted from account balance. (NOTE: If enrolling with an employer group, this fee may be paid in full, or in part, by your employer.)
Mutual Fund Specific Fee: 6.25* basis points per quarter (i.e., $0.625 cents per $1,000 every three months). Fees will be deducted from the account balance quarterly.
* Vanguard® funds only
Transactional Fees
Debit Card Fees (if applicable)
Withdrawals via paper check
$10
Replace lost or stolen debit card
$12
Excess contribution correction
$25
Additional charge (per card) for three or more debit cards
$6
Non-sufficient funds (NSF)
$30
Stop payment
$25
Transaction correction
$25
Copy of debit card merchant receipt
$25
Wire transfer (sent or received)
$25
Terminate debit card access
$25
Duplicate copy of tax document
$4
Transfer/rollover to another custodian
$25
Account closure
$25
INTEREST SCHEDULE
There is no minimum account balance required to open a health savings account or to obtain the annual percentage yield disclosed. Interest is credited monthly and based on the
balance in your cash/debit card account. The interest rate available on your account is as follows, effective as of September 1, 2015.
Balance
Interest Rate
Balance
Interest Rate
$25,000 or more
0.50%
$5,000.00 – $9,999.99
0.20%
$15,000.00 – $24,999.99
0.40%
$2,500.00 – $4,999.99
0.10%
$10,000.00 – $14,999.99
0.30%
Less than $2,500
0.05%
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TERMS AND CONDITIONS
Section 1: Scope of Agreement
Section 8: Application of Law
Your agreement with FPS Trust Company, LLC (“FPS”) consists of the terms set forth in
the HSA Enrollment and Agreement Form and the terms of the custodial account agreement between FPS and your employer. In addition, you may, in the future, receive from
FPS, supplemental terms and disclosures which shall also be a part of the agreement
between you and FPS (collectively, the “Agreement and Disclosure”.) You agree to read
the Agreement and Disclosures carefully and to retain copies for your records.
What Law Applies: This Agreement is subject to all applicable federal and state laws and
regulations and any mutually agreed-upon arbitration agreements. If it is necessary to
apply any state law to interpret and administer this Agreement, the law of our domicile shall
govern. If any part of this Agreement is held to be illegal or invalid, the remaining parts
shall not be affected. Neither your nor our failure to enforce at any time or for any period of
time any of the provisions of this Agreement shall be construed as a waiver of such provisions, or your right or our right thereafter to enforce each and every such provision.
Section 2: Acceptance of Agreement and Disclosures
Section 9: Electronic Copies
You agree that the Agreement and Disclosures govern all aspects of your relationship with
FPS, including all transactions between FPS and you and all products and services now or
in the future offered through FPS. FPS may rely on your use of FPS’s products and services as evidence of your continued acceptance of the Agreement and Disclosures.
The electronically stored copy of your (or your agent’s) signature, any written instructions
or authorizations, the HSA Enrollment and Agreement Form and the Agreement and Disclosures is considered to be the true, complete, valid, authentic and enforceable record,
admissible in judicial, administrative or arbitration proceedings to the same extent as if the
documents and records were originally generated and maintained in printed form. You
agree to not contest the admissibility or enforceability of FPS’s electronically stored copy of
such documents in any proceeding between you and FPS.
Section 3: Your Representations and Warranties
You represent and warrant that: (a) you are of legal age in the state in which you live and
you are authorized to enter into this Agreement; (b) you have supplied accurate information in your Account Application (c) no additional authorizations from third parties are
required for you to open the Account and effect transactions therein; (d) except as you
have otherwise indicated on your HSA Enrollment and Agreement Form or in writing to us,
(i) you are not an employee of or affiliated with any securities exchange or member firm of
any exchange, the Financial Industry Regulatory Authority (FINRA), or any securities firm,
bank, trust company or insurance company and (ii) you are not a director, 10% benefit
shareholder, policymaking officer or otherwise an “affiliate” (as defined in Rule 144 under
the Securities Act of 1933) of a publicly traded company and (e) this Application Agreement, as amended from time to time, is a legal, valid and binding obligation, enforceable
against you in accordance with its terms.
Section 10: Allocation of Contributions
You may place your contributions in one fund or in any combination of funds, although your
employer may place restrictions on investment in certain funds.
Section 11: Compliance
I understand that in the event my Participant Enrollment form is incomplete or is not received by Health Savings Administrators at the address stated on this HSA Enrollment and
Agreement Form prior to the receipt of any deposits, FPS will hold these deposits until I
supply Health Savings Administrators with a completed form.
Section 4: Account Handling
Section 12: Incomplete Forms
The Designated Custodian (“The Custodian”) will automatically hold all of your securities
purchased, sales proceeds, dividends and interest. The Custodian will also release your
name, address and securities positions to authorized agencies and entities, including
companies in which we hold securities for your Account, upon request, unless you notify us
otherwise in writing.
I understand that it is my obligation to review all confirmations and quarterly statements for
discrepancies or errors. Corrections will be made only for errors which I communicate
within 90 calendar days of the last calendar quarter. After this 90 day period, account
information shall be deemed accurate and acceptable to me. If I notify FPS of an error after
this 90 day period, the correction will be only processed from the date of notification forward and not on a retroactive basis.
Section 5: Responsibility for Investment Decisions
Section 13: Provider Compensation
You agree that you and any agent under a power of attorney or Investment Advisor (if you
have one) are solely responsible for investment decisions in your Account, including
whether to buy or sell a particular security. Unless required by law, you understand that
FPS has no obligation to determine whether a particular transaction, strategy or purchase
or sale of a security is suitable for you. Your obligation includes an affirmative duty to
monitor and stay informed about your Account and your investments and respond to
changes as you deem appropriate. Unless FPS otherwise agrees with you in writing, FPS
does not have any discretionary authority or obligation to review or make recommendations for the investment of securities or cash in your Account. You acknowledge that FPS
and Health Savings Administrators do not provide tax or legal advice.
FPS receives compensation from certain funds or their affiliates and other investment
providers in consideration for services that FPS provides including but not limited to 1)
participant statements 2) maintaining participant level fund accounting 3) transmitting and
recording purchase and redemption instructions for such investments 4) transaction settlement 5) prospectus and fact sheet delivery and 6) participant call center services. This
compensation is paid directly to FPS by the funds or investment provider, their affiliates, or
services provider pursuant to a service agreement between FPS and one or more such
parties, and the Employer is not responsible for payment of this compensation. The compensation paid to FPS is based either on a percentage of the average daily net asset value
or each investment or on a set fee per each investment option in which a participant inSection 6: Liquidations
vests. Asset-based compensation can range from 0.00% to 0.25% annually on average
Whenever it is necessary for our protection or to satisfy a debit or other obligation owed us, assets, while investments paying a set fee can range from $10 to $12 annually per participant account. The fees received by FPS may be used to offset the fees that would otherwe may (but are not required to) sell, assign and deliver all or any part of the property
securing your obligations, or close any or all transactions in your Account or restrict activity wise be charged to the Plan or Account, dependent upon plan type.
in your Account. We may choose which property to buy or sell, which transactions to close
and the sequence and timing of liquidation.
We may take such actions on whatever exchange or market and in whatever manner
(including public auction or private sale) that we choose in the exercise of our business
judgment. You agree not to hold us liable for the choice of which property to buy or sell or
of which transactions to close or for timing or manner of liquidation or any tax consequences from such actions. All of the above may be done without demand or notice of purchase,
sale, transfer or cancellation to you. No demand or notice shall impose on FPS any obligation to make such demand or provide such notice to you in the future. Any such notice or
demand is hereby expressly waived, and no specific demand or notice shall invalidate this
waiver.
Section 7: Verification
You authorize FPS to inquire from any source, including a consumer reporting agency, as
to the identity (as required by law), creditworthiness and ongoing eligibility for the Account
of yourself, any other person referred to on this Application, or any person whom FPS is
later notified is associated with or has an interest in the account at account opening, at any
time throughout the life of the Account, and thereafter for debt collection or investigative
purposes.
6
PRIVACY POLICY
Facts
What Does FPS Trust Company, LLC Do With Your Personal Information?
Why?
To help you better understand how your personal information is protected at FPS Trust Company, LLC, we are providing
you with the following information describing our practices and policies with respect to the privacy of your customer information. In the event you terminate your customer relationship with us, or become an inactive customer, we will continue
to adhere to the policies and practices described in this notice.
What ?



The types of personal information we collect can include:



Social Security number
Income
Assets
Investment experience
Account transactions
Retirement assets
When you are no longer our customer, we will continue to hold your information and share it as described in this notice.
How?
All financial companies need to share customers’ personal information to run their everyday business. In the section
below, we list the reasons financial companies can share their customers’ personal information; the reasons FPS Trust
Company (FPS) choose to share; and whether you can limit this sharing.
Reasons we can share your personal information
Does FPS share?
Can you limit sharing?
For our everyday business purposes
Such as to process and service your transactions, report on transactions,
Yes
maintain your account(s), respond to court orders, regulatory and legal
investigations, or report to credit bureaus.
No
For our marketing purposes
To offer our products and services to you.
No
We don’t share
For joint marketing with other financial companies
No
We don’t share
For our affiliates’ everyday business purposes
No
We don’t share
For our affiliates or nonaffiliates to market to you
No
We don’t share
What We Do
How does FPS protect my personal information?
To protect your personal information from unauthorized access and use, we
use security measures to comply with federal law. These measures include
safeguards and secured files and buildings.
We require companies that help provide our services to you protect the confidentiality of personal information they receive.
We collect your personal information, for example, when you:
How does FPS collect my personal information?

Open an account or deposit money

Pay fees or conduct other transactions through your account
We also collect your personal information from others such as affiliates or
other companies.
Federal law gives you the right to limit only:
Why can’t I limit all of my sharing?

Sharing for affiliates’ everyday business purposes

Affiliates from using your information to market to you

Sharing for nonaffiliates
State laws and individual companies may give you additional rights to limit
sharing.
7